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System Design Lessons from the USS McCain

The Navy installed touch-screen steering systems to save money.

Ten sailors paid with their lives.

ProPublica
USS McCain in 2019 (U.S. Navy Photo)

Ten sailors died after the crew of the destroyer USS John S. McCain lost control of their vessel, causing a collision with the merchant tanker Alnic MC. There was nothing technically wrong with the vessel or its controls. Though much of the blame was put on the Sailors and Officers aboard, the real fault rests with the design of the Integrated Bridge & Navigation System (IBNS).

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Human Factors Design Drives System Performance

Bottom Line Up Front:

  • Human performance is a major factor in overall system performance
  • Humans are increasingly the bottleneck for system performance
  • Human factors engineering design drives human performance and thus system performance

Why care about humans?

In many system development efforts, the focus is on the capabilities of the technology: How fast can the jet fly? How accurately can the rifle fire?

We can talk about the horsepower of the engines and the boring of the rifle until the cows come home, but without a human pressing the throttle or pulling the trigger, neither technology is doing anything. A major mistake many systems engineering efforts experience is neglecting the impact of the human on the performance of the system.

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The Swiss cheese model: Designing to reduce catastrophic losses

Failures and errors happen frequently. A part breaks, an instruction is misunderstood, a rodent chews through a power cord. The issue gets noticed, we respond to correct it, we clean up any impacts, and we’re back in business.

Occasionally, a catastrophic loss occurs. A plane crashes, a patient dies during an operation, an attacker installs ransomware on the network. We often look for a single cause or freak occurrence to explain the incident. Rarely, if ever, are these accurate.

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System lexicons and why your project needs one

A system lexicon is a simple tool which can have a big impact on the success of the system. It aligns terminology among technical teams, the customer, subcontractors, support personnel, and end users. This creates shared understanding and improves consistency. Read on to learn how to implement this powerful tool on your program.

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The Role of the Human Systems Integrator

This article is required reading for anyone who needs to hire, wants to become, or is going to be working with an HSI expert. Understand what the job entails, the key skills required, and how it relates to the rest of the systems engineering effort.

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